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ACCIDENT SERVICES
78
ACCIDENT SERVICES
Urgent Need for Organisation " At a time when this country has applied itself earnestly to social problems and to the conquest of disease, it has failed to take proper action to reduce disablement from injury." Believing that the organisation of fracture and accident services is gravely deficient, the British Orthopaedic Association has produced a new memorandum calling urgently for action. Casualties, it says, are diffused too widely among too many small hospitals, few, of which deal with them satisfactory.
can
"
It is not in the best interests of a severely injured patient that he be conveyed to the nearest hospital, if that hospital is not equipped and staffed to deal properly with his injuries. It is usually far better for him to be taken the extra distance. to a hospital that is prepared for this special work, even though the ambulance may pass other hospitals on the way . Serious delay in the treatment of the injured occurs, not in transit to hospital, but within the hospital that receives the casualties-through poor organisation and inadequate
facilities.
services. The average requirement is between 150 and 250 accident beds per half-million of the population, assuming that beds for convalescence are also available, especially for the elderly. 12, Since injuries of the locomotor system account for three-quarters of all injuries it is clear that the main responsibility must fall upon orthopaedic surgeon.-;, one of whom should be in administrative charge of the accident service But those in other specialtes are needed to share the burden. The oithopaedic surgeon should confine his responsibility for treatment to injuries deal of the limbs and spine: the neurosurgeon will with injuries of the head-, the thoracic surgeon with injuries, of the chest, the abdominal surgeon with visceral injuries, the plastic surgeon with burns, and so on. The closer the collaboration between the various consultants the better. Here it must be emphasised that it is unrealistic to attempt to train surgeons to be expert in every field of surgery-locomotor, abdominal, urogenital, cardiac, thoracic, cerebral—or in injuries of every part. The creation of casualty surgeons " who accept full responsibility for the treatment of injuries in every of part of the body would therefore be an undesirable deve-
ancillary
Special Articles
"
The Association urges H.M. Government to act the following recommendations :
on
1. Accident services should be organised on a nationwide scale to provide adequate accommodation, equipment, and staff for the treatment of all varieties of injury, under the best conditions, at any time of the day or
night.
2. The country should be divided into areas, each with its comprehensive accident unit based upon an existing general hospital. This divison should apply to large cities as well as to country districts, and in general having regard to population and distance the size of each area should be such that a twenty-four-hour service be maintained economically at the hospital selected for the purpose. Often the accident unit could be sited in relation to main trunk roads and industrial concentranumber of small towns, first-aid units should be established in peripheral hospitals. They sould all form part of the accident service with its headquarters at the general hospital designated for this purpose. 3. At hospitals designated as accident centres this staff structure should be overhauled, to ensure full supervision by experienced orthopaedic surgeons, to provide more adequate staff of intermediate grade than is at present available, and to enrol interested general practitioners. 4, Hospitals not designated as accident centres should be discouraged from receiving injured patients. Patients arriving there under special circumstances should be treatsd if the injury is a minor one, but all patients with serious injuries should be transferred to the appropriate accident unit as soon as possible. 5. The ambulance services should be adjusted to meet these provisions.
can
STRUCTURE AND ORGANISATION OF AX ACCIDENT SERVICE
The Accldent Unit. 6. The central unit should be a department of age. neral hospital. The accommodation, for both out patients and for mpatients, should be in one block with It should contain all its own entrance for ambulances. the facilities needed for reception and immediate treatment, including its own X-ray unit, operation theatre or theatres and the necessary ancillary services. 7. The accident unit should be responsible for the reception of all injured patients. 8. It should have immediately available every facility for the resuscitation of the severely injured. 9. It should provide for the continued treatment of all patients with injuries of the locomotor system and of patients with multiple injuries. The continued treatment of patients with other types of injury-such as those of the head, chest, abdomen, or eyes-should beof the appropriate specialist come the responsibility department of the hospital. Accommodation and Staff. 11. There would necessarily be considerable variations according to the nature of the area served. The size of each unit should be such that it is economical to maintain a full twenty-four-hour service with all its
"
lopment. of the junior staffing new It will not be possible to rely entirely on the shortterm employment of young men in training for consultant appointments, although these men will continue to fulfilan important function. General practitioners who have a special interest in this kind of work could carry considerable responsibility if their services were properly organised. With general practitioners and junior surgical staff the dominant requirement is integration in a proper team, with unremitting supervision 13y the consultants and with full facilities for consultation and the exchange of ideas. 13.
Upon the character
thought is required.
Peripheral Hospitals. 14. However efficiently an accident unit may work it cannot of itself provide a solution to the whole problem of accidents. Accidents are unpredictable and urgent and above all ubiquitous. The peripheral hospitals have a vital role, and as much thought should be given to their equipment and staffing as is required for the accident unit.
The central
unit and the
peripheral hos-
pitals together form the accident service. availableat all times of day There should be night-a rota would be necessary—a clinician who experienced in two respects. He must be able to distinguish between the minor injury and the injury that
15. and
actually or potentially serious. In. the latter case the patient will be sent on to the accident unit when fit to
is
travel : 3n apparently minor injury, such as a cut in the hand that may involve a tendon sheath, must be recognised and the patient sent, as a matter of urgency, to the unit. This clinician must also be competent accident to deal efficiently with minor injuries-the small superficial burn, the Colles’s fracture, the sprained ankle, A surgeon resident in a small town, or a general practitioner, is the right man for this work, provided that his training in accident surgery is adequate. He is as much a part of the accident service as a man in the central unit, and it is the duty of the surgeon in charge of the service to ensure an effective liaison between the unit and its peripheral hospitals and their staffs.
Casualty Departments. other than acci16. Emergency receiving rooms for dent cases will still be needed in designated hospitals, but sasualty departments as they used to be known should exist no longer.
Rehabilitation. 17. or
of supervision up to the stage of fuD possible recovery and until the time of resettlement is essential, and full provision
Continuity
greatest
occupational
for rehabilitation should be made. It is cardinal, however, that the clinical and functional result depends most on the standard of primary treatment, which is thus the most important single step in rehabilitation. Teaching in Accident Surgery. 18. It is recommended that the academic boards of medical schools should give greater attention to this It has already been indicated that aspect of medicine. where comprehensive accident services have been established the teaching of medical students has been greatly simplified and improved. The hospitals designated for complete fracture and accident units would almost invariably include every teaching hospital. Even if in these teaching hospitals the allocation of beds to accident cases were necessarily limited by other teaching requirements, there could still be planned an association
79 Observations by Mr. T.B. BATTERSBY led him to suggest that early repair of the palatal cleft produced growth restriction of the maxillllæ. He concluded that palate repair should be delayed until the age of5 years. Dr. FRANCIS BURIAN (Czechoslovakia) put forward a ple:
with another hospital to which injured patients were transferered within a few days of their primary treatment, still under the same control, and still available for the teaching of undergraduate and postgraduate stu-
dents,
19. The British Orthopaedic Association supports, and recommends the support of, the Royal Colleges of Surgeons in their insistence on training in accident surgery before candidates sit for the Fellowship examinations. Good training and the provision of efficently organised services will go far to encourage the recruitment of the younger men to work in accident departments: not
for international collaboration in precipitating cleft lip and palate
assessing the and
factors results of
the
treatment. Anaesthesia
Dr. G.E. HALE ENDERBY advocated hypotension in plastic
Operative success was more certain, visihility being improved; and postoperative hæmatoma was less
surgery.
In 7000 cases only 2 instances of cerebroascular accident had been encountered. Dr. D. MOREL-FATIO (France) enumerated the advantages of local anaesthesia with basal premedication for plastic surgery of the face. Bleeding could be reduced considerably with this method.
only does this apply to
surgeons, but also to ancillary avoid this work because of the are ft present found. Postgraduate courses, which should include practical instruction, should be available to general practitioners, Here the who should be encouraged to attend them. interest of the College of General Practitioners might
common.
well be sought.
Corrections of jaw deformities, such as prognathism, mandibular retrusion, and open bite, were described by Dr. KAHL SCHUCHARDT (Gertnany). Intraoral methods were more succec,sful now that sepsis could be controlled and accurate jaw alignment achieved. Dr. Ivo CUPAR (Jugoslavia) advocated internal fixation with stainless steel plates following section of the ver-
many of whom staff, discouragements that
The organisation of accident services must be undertaken by the State as a quasi-military operation. To provide the whole country with integrated accident services on the lines suggested in this memorandum will clearly mean the expenditure of considerable sums of money over many years. Nevertheless a beginning must be made ; and the British OrthopaedicAssociation recommends that the Government should authorise each regional hospital board, in conjunction with boards of governors of teaching hospitals, to set up
forthwith at least one comprehensive accident service within its area. In the fullness of time such units would be multiplied and integrated to form a nationWide service. -
Congresses
THE International Congress of Plastic Surgery was held in London on July 12-17, under the presidency of Mr. RAINSFORD MOWLEM. Cleft Lip and Palate Dr. ROBERT H. IVY (U.S.A.) said that both hereditary and environmental factors play a part in the ætiology of cleft lip and palate; and he stressed the necessity for further research to discover and eliminate external causes. Dr. JOACHIM GABA (Germany) noted that cortisone may be such a cause. Observations in mice by Dr. LYNDON A. PEER (U.S.A.) have shown that vitamin Be and folic acid both reduce the incidence of cortisone-induced cleft palate. These compounds have been given to a few pregnant women, and Dr. Peer’s impressiun is that they may be of clinical value. Work is being carried out in Liverpool by Mr. R.P. OSBORNE, Mr. D.A. KERNAHAN, and Dr. W.R. BURSTON on embryology and treatment. Mr. Kernahan suggested a new classification for cleft palate, based on the embryology ; and he discussed the deformities resulting from failure of growth coordination between the iiitraorhitonasal septum and maxillæ. The malalignment of the alveolar segments in unilateral and bilateral clefts is means
of dental
plates.
Dr. Burston starts this orthoppedie correction when the haby is a few days old. Alr. Osborne said that alveolar
collapse
was
an
important
factor in
tical ramus in the treatment of maudibular prognathism in edentulous jaws. Dr. ALLAX RAGNELL (Sweden) described his twenty years’ experience with autogenous bone grafts building up deformities of the facial sqeleton. He felt that such bone grafts were superior to other materials. in
Cancer
Head
the
and
Neck
cases of cancer wide block excision with immediate reconstruction. Dr. W.B. MACOMBER (U.S.A.) described the treatment of cancer of the eyelids by ablation followed by reconstruction, by means of a tarsal pedicle and a full-thickness skin graft. Dr. E.V. GIBSON (Australia) suggested that in basal-cell carcinomas definitive reconstruction should often be
Dr. C.L. KIEHN (U.S.A.) recommended in
delayed until recurrence was unlikely, temporary repair being achieved by split-skin grafts. Dr. HELENE Jawtr.tt (France) agreed that the temporary use of a free skin graft aided early recognition of recurrence. In cases of cancer arising in burn scars. Dr. R.F.E. MOULY (France) advised primary excision and skin graft.
PLASTIC SURGERY
corrected before lip repair by
Bone Deformities
producing
a
poor
appearance, and speech and eating defects; such collapse should be corrected from the onset of treatment. Dr. WOLFGANG ROSENTHAL (Germany) proposed a different approach-repairing only the soft palate at the age of 6 months, and leaving the repair of the hard palate until later. Dr. T.D. FOSTER reviewed the maxillomandibular relationship in normal and cleft cases, showing that some basic growth defect was present in certain types of palatal cleft. Mr. D. GREER WALKER, discussing such ii-iaxillomandibular deformities, suggested that the study of dogs should be informative, as different breeds illustrated relative prognatism and retrusion.
Transplantation of Teeth Dr. S.W. LESLIE (Canada) described cases of transplanfation of teeth; a tooth had been successfully transferred from a girl to her brother. .
The Injured Hand Dr. C.C. SNYDER (U.S.A.) discussed electrical burns of the hand. He advocated nerve pedicle grafts for loss of
than 8 cm. of tierve; free grafts were useful for shorter lengths. Dr. J.W. LITTLER (U.S.A.) deseribed methods of transposing sensitive skin from less essential areas of the fingers, to restore sensitivity to the pulp aspect of the thumb. Transplation of autogenous hones and joints was recommended hv Dr. M.A. ENTIN (Canada) as a salvaging procedure in the severely injured hand. Dr. J.F. ELY (Brazil), discussing skin restoration in digital injuries, emphasised the importance of early cover. Mr. S.H. HAHmsox discussed the divided flexor profundus tendon, and described repair hy tendon grating with retention of half the flexor sublimis tendon. Primary repair of the divided flexor profundus tendon in cutlass injuries was advocated by Dr. E.l..S. ROBERTSON (British West Indies). In reconstuction of the thumb Dr. B’. KARFIK (Czechtrv slovakia) uses a V-shaped eartilage graft from the 8th and 9th ribs. one stem being fixed to the metacarpal bone of the index finger. Dr. ORLOV (U.S.S.R.) deseribed local anæsthesia in the hand by injection of 30-60 ml. of 0.25-0.5% novocaïne into the heads of the radius and ulna; tourniquet is applied to the upper arm.
more
‘
Skull
Defects
Dr. J.J. LONGACRE (U.S.A.) described the use of split rib grafts to restore defects of the calvarium. Others advocated tantulum plates (Dr. E.C. Hinds [U.S.A.], vitallium plates (Dr. I. Clerici-Bagozzi [Italy] and polyethylene and polyvinylchloride (;rtizcikoN., [U.S.S.R. ).
plastic
compounds
(Dr.
E.V.
Construction of Pinna
Techtnfjucs congenitally
for
the hinna where this is described by Mr. A.J. EVANS
constructing
ahsent
were
ACCIDENT SERVICES
Urgent Need for Organisation " At a time when this country has applied itself earnestly to social problems and to the conquest of disease, it has failed to take proper action to reduce disablement from injury." Believing that the organisation of fracture and accident services is gravely deficient, the British Orthopaedic Association has produced a new memorandum calling urgently for action. Casualties, it says, are diffused too widely among too many small hospitals, few, of which deal with them satisfactory.
can
"
It is not in the best interests of a severely injured patient that he be conveyed to the nearest hospital, if that hospital is not equipped and staffed to deal properly with his injuries. It is usually far better for him to be taken the extra distance. to a hospital that is prepared for this special work, even though the ambulance may pass other hospitals on the way . Serious delay in the treatment of the injured occurs, not in transit to hospital, but within the hospital that receives the casualties-through poor organisation and inadequate
facilities.
services. The average requirement is between 150 and 250 accident beds per half-million of the population, assuming that beds for convalescence are also available, especially for the elderly. 12, Since injuries of the locomotor system account for three-quarters of all injuries it is clear that the main responsibility must fall upon orthopaedic surgeon.-;, one of whom should be in administrative charge of the accident service But those in other specialtes are needed to share the burden. The oithopaedic surgeon should confine his responsibility for treatment to injuries deal of the limbs and spine: the neurosurgeon will with injuries of the head-, the thoracic surgeon with injuries, of the chest, the abdominal surgeon with visceral injuries, the plastic surgeon with burns, and so on. The closer the collaboration between the various consultants the better. Here it must be emphasised that it is unrealistic to attempt to train surgeons to be expert in every field of surgery-locomotor, abdominal, urogenital, cardiac, thoracic, cerebral—or in injuries of every part. The creation of casualty surgeons " who accept full responsibility for the treatment of injuries in every of part of the body would therefore be an undesirable deve-
ancillary
Special Articles
"
The Association urges H.M. Government to act the following recommendations :
on
1. Accident services should be organised on a nationwide scale to provide adequate accommodation, equipment, and staff for the treatment of all varieties of injury, under the best conditions, at any time of the day or
night.
2. The country should be divided into areas, each with its comprehensive accident unit based upon an existing general hospital. This divison should apply to large cities as well as to country districts, and in general having regard to population and distance the size of each area should be such that a twenty-four-hour service be maintained economically at the hospital selected for the purpose. Often the accident unit could be sited in relation to main trunk roads and industrial concentranumber of small towns, first-aid units should be established in peripheral hospitals. They sould all form part of the accident service with its headquarters at the general hospital designated for this purpose. 3. At hospitals designated as accident centres this staff structure should be overhauled, to ensure full supervision by experienced orthopaedic surgeons, to provide more adequate staff of intermediate grade than is at present available, and to enrol interested general practitioners. 4, Hospitals not designated as accident centres should be discouraged from receiving injured patients. Patients arriving there under special circumstances should be treatsd if the injury is a minor one, but all patients with serious injuries should be transferred to the appropriate accident unit as soon as possible. 5. The ambulance services should be adjusted to meet these provisions.
can
STRUCTURE AND ORGANISATION OF AX ACCIDENT SERVICE
The Accldent Unit. 6. The central unit should be a department of age. neral hospital. The accommodation, for both out patients and for mpatients, should be in one block with It should contain all its own entrance for ambulances. the facilities needed for reception and immediate treatment, including its own X-ray unit, operation theatre or theatres and the necessary ancillary services. 7. The accident unit should be responsible for the reception of all injured patients. 8. It should have immediately available every facility for the resuscitation of the severely injured. 9. It should provide for the continued treatment of all patients with injuries of the locomotor system and of patients with multiple injuries. The continued treatment of patients with other types of injury-such as those of the head, chest, abdomen, or eyes-should beof the appropriate specialist come the responsibility department of the hospital. Accommodation and Staff. 11. There would necessarily be considerable variations according to the nature of the area served. The size of each unit should be such that it is economical to maintain a full twenty-four-hour service with all its
"
lopment. of the junior staffing new It will not be possible to rely entirely on the shortterm employment of young men in training for consultant appointments, although these men will continue to fulfilan important function. General practitioners who have a special interest in this kind of work could carry considerable responsibility if their services were properly organised. With general practitioners and junior surgical staff the dominant requirement is integration in a proper team, with unremitting supervision 13y the consultants and with full facilities for consultation and the exchange of ideas. 13.
Upon the character
thought is required.
Peripheral Hospitals. 14. However efficiently an accident unit may work it cannot of itself provide a solution to the whole problem of accidents. Accidents are unpredictable and urgent and above all ubiquitous. The peripheral hospitals have a vital role, and as much thought should be given to their equipment and staffing as is required for the accident unit.
The central
unit and the
peripheral hos-
pitals together form the accident service. availableat all times of day There should be night-a rota would be necessary—a clinician who experienced in two respects. He must be able to distinguish between the minor injury and the injury that
15. and
actually or potentially serious. In. the latter case the patient will be sent on to the accident unit when fit to
is
travel : 3n apparently minor injury, such as a cut in the hand that may involve a tendon sheath, must be recognised and the patient sent, as a matter of urgency, to the unit. This clinician must also be competent accident to deal efficiently with minor injuries-the small superficial burn, the Colles’s fracture, the sprained ankle, A surgeon resident in a small town, or a general practitioner, is the right man for this work, provided that his training in accident surgery is adequate. He is as much a part of the accident service as a man in the central unit, and it is the duty of the surgeon in charge of the service to ensure an effective liaison between the unit and its peripheral hospitals and their staffs.
Casualty Departments. other than acci16. Emergency receiving rooms for dent cases will still be needed in designated hospitals, but sasualty departments as they used to be known should exist no longer.
Rehabilitation. 17. or
of supervision up to the stage of fuD possible recovery and until the time of resettlement is essential, and full provision
Continuity
greatest
occupational
for rehabilitation should be made. It is cardinal, however, that the clinical and functional result depends most on the standard of primary treatment, which is thus the most important single step in rehabilitation. Teaching in Accident Surgery. 18. It is recommended that the academic boards of medical schools should give greater attention to this It has already been indicated that aspect of medicine. where comprehensive accident services have been established the teaching of medical students has been greatly simplified and improved. The hospitals designated for complete fracture and accident units would almost invariably include every teaching hospital. Even if in these teaching hospitals the allocation of beds to accident cases were necessarily limited by other teaching requirements, there could still be planned an association
79 Observations by Mr. T.B. BATTERSBY led him to suggest that early repair of the palatal cleft produced growth restriction of the maxillllæ. He concluded that palate repair should be delayed until the age of5 years. Dr. FRANCIS BURIAN (Czechoslovakia) put forward a ple:
with another hospital to which injured patients were transferered within a few days of their primary treatment, still under the same control, and still available for the teaching of undergraduate and postgraduate stu-
dents,
19. The British Orthopaedic Association supports, and recommends the support of, the Royal Colleges of Surgeons in their insistence on training in accident surgery before candidates sit for the Fellowship examinations. Good training and the provision of efficently organised services will go far to encourage the recruitment of the younger men to work in accident departments: not
for international collaboration in precipitating cleft lip and palate
assessing the and
factors results of
the
treatment. Anaesthesia
Dr. G.E. HALE ENDERBY advocated hypotension in plastic
Operative success was more certain, visihility being improved; and postoperative hæmatoma was less
surgery.
In 7000 cases only 2 instances of cerebroascular accident had been encountered. Dr. D. MOREL-FATIO (France) enumerated the advantages of local anaesthesia with basal premedication for plastic surgery of the face. Bleeding could be reduced considerably with this method.
only does this apply to
surgeons, but also to ancillary avoid this work because of the are ft present found. Postgraduate courses, which should include practical instruction, should be available to general practitioners, Here the who should be encouraged to attend them. interest of the College of General Practitioners might
common.
well be sought.
Corrections of jaw deformities, such as prognathism, mandibular retrusion, and open bite, were described by Dr. KAHL SCHUCHARDT (Gertnany). Intraoral methods were more succec,sful now that sepsis could be controlled and accurate jaw alignment achieved. Dr. Ivo CUPAR (Jugoslavia) advocated internal fixation with stainless steel plates following section of the ver-
many of whom staff, discouragements that
The organisation of accident services must be undertaken by the State as a quasi-military operation. To provide the whole country with integrated accident services on the lines suggested in this memorandum will clearly mean the expenditure of considerable sums of money over many years. Nevertheless a beginning must be made ; and the British OrthopaedicAssociation recommends that the Government should authorise each regional hospital board, in conjunction with boards of governors of teaching hospitals, to set up
forthwith at least one comprehensive accident service within its area. In the fullness of time such units would be multiplied and integrated to form a nationWide service. -
Congresses
THE International Congress of Plastic Surgery was held in London on July 12-17, under the presidency of Mr. RAINSFORD MOWLEM. Cleft Lip and Palate Dr. ROBERT H. IVY (U.S.A.) said that both hereditary and environmental factors play a part in the ætiology of cleft lip and palate; and he stressed the necessity for further research to discover and eliminate external causes. Dr. JOACHIM GABA (Germany) noted that cortisone may be such a cause. Observations in mice by Dr. LYNDON A. PEER (U.S.A.) have shown that vitamin Be and folic acid both reduce the incidence of cortisone-induced cleft palate. These compounds have been given to a few pregnant women, and Dr. Peer’s impressiun is that they may be of clinical value. Work is being carried out in Liverpool by Mr. R.P. OSBORNE, Mr. D.A. KERNAHAN, and Dr. W.R. BURSTON on embryology and treatment. Mr. Kernahan suggested a new classification for cleft palate, based on the embryology ; and he discussed the deformities resulting from failure of growth coordination between the iiitraorhitonasal septum and maxillæ. The malalignment of the alveolar segments in unilateral and bilateral clefts is means
of dental
plates.
Dr. Burston starts this orthoppedie correction when the haby is a few days old. Alr. Osborne said that alveolar
collapse
was
an
important
factor in
tical ramus in the treatment of maudibular prognathism in edentulous jaws. Dr. ALLAX RAGNELL (Sweden) described his twenty years’ experience with autogenous bone grafts building up deformities of the facial sqeleton. He felt that such bone grafts were superior to other materials. in
Cancer
Head
the
and
Neck
cases of cancer wide block excision with immediate reconstruction. Dr. W.B. MACOMBER (U.S.A.) described the treatment of cancer of the eyelids by ablation followed by reconstruction, by means of a tarsal pedicle and a full-thickness skin graft. Dr. E.V. GIBSON (Australia) suggested that in basal-cell carcinomas definitive reconstruction should often be
Dr. C.L. KIEHN (U.S.A.) recommended in
delayed until recurrence was unlikely, temporary repair being achieved by split-skin grafts. Dr. HELENE Jawtr.tt (France) agreed that the temporary use of a free skin graft aided early recognition of recurrence. In cases of cancer arising in burn scars. Dr. R.F.E. MOULY (France) advised primary excision and skin graft.
PLASTIC SURGERY
corrected before lip repair by
Bone Deformities
producing
a
poor
appearance, and speech and eating defects; such collapse should be corrected from the onset of treatment. Dr. WOLFGANG ROSENTHAL (Germany) proposed a different approach-repairing only the soft palate at the age of 6 months, and leaving the repair of the hard palate until later. Dr. T.D. FOSTER reviewed the maxillomandibular relationship in normal and cleft cases, showing that some basic growth defect was present in certain types of palatal cleft. Mr. D. GREER WALKER, discussing such ii-iaxillomandibular deformities, suggested that the study of dogs should be informative, as different breeds illustrated relative prognatism and retrusion.
Transplantation of Teeth Dr. S.W. LESLIE (Canada) described cases of transplanfation of teeth; a tooth had been successfully transferred from a girl to her brother. .
The Injured Hand Dr. C.C. SNYDER (U.S.A.) discussed electrical burns of the hand. He advocated nerve pedicle grafts for loss of
than 8 cm. of tierve; free grafts were useful for shorter lengths. Dr. J.W. LITTLER (U.S.A.) deseribed methods of transposing sensitive skin from less essential areas of the fingers, to restore sensitivity to the pulp aspect of the thumb. Transplation of autogenous hones and joints was recommended hv Dr. M.A. ENTIN (Canada) as a salvaging procedure in the severely injured hand. Dr. J.F. ELY (Brazil), discussing skin restoration in digital injuries, emphasised the importance of early cover. Mr. S.H. HAHmsox discussed the divided flexor profundus tendon, and described repair hy tendon grating with retention of half the flexor sublimis tendon. Primary repair of the divided flexor profundus tendon in cutlass injuries was advocated by Dr. E.l..S. ROBERTSON (British West Indies). In reconstuction of the thumb Dr. B’. KARFIK (Czechtrv slovakia) uses a V-shaped eartilage graft from the 8th and 9th ribs. one stem being fixed to the metacarpal bone of the index finger. Dr. ORLOV (U.S.S.R.) deseribed local anæsthesia in the hand by injection of 30-60 ml. of 0.25-0.5% novocaïne into the heads of the radius and ulna; tourniquet is applied to the upper arm.
more
‘
Skull
Defects
Dr. J.J. LONGACRE (U.S.A.) described the use of split rib grafts to restore defects of the calvarium. Others advocated tantulum plates (Dr. E.C. Hinds [U.S.A.], vitallium plates (Dr. I. Clerici-Bagozzi [Italy] and polyethylene and polyvinylchloride (;rtizcikoN., [U.S.S.R. ).
plastic
compounds
(Dr.
E.V.
Construction of Pinna
Techtnfjucs congenitally
for
the hinna where this is described by Mr. A.J. EVANS
constructing
ahsent
were